title: Boundaries of schizoaffective disorder: revisiting Kraepelin.
abstract: OBJECTIVE
  Established nosology identifies schizoaffective disorder as a distinct category with boundaries separating it from mood disorders with psychosis and from schizophrenia. Alternative models argue for a single boundary distinguishing mood disorders with psychosis from schizophrenia (kraepelinian dichotomy) or a continuous spectrum from affective to nonaffective psychosis.
  
  
  OBJECTIVE
  To identify natural boundaries within psychotic disorders by evaluating associations between symptom course and long-term outcome.
  
  
  METHODS
  The Suffolk County Mental Health Project cohort consists of first-admission patients with psychosis recruited from all inpatient units of Suffolk County, New York (72% response rate). In an inception cohort design, participants were monitored closely for 4 years after admission, and their symptom course was charted for 526 individuals; 10-year outcome was obtained for 413.
  
  
  METHODS
  Global Assessment of Functioning (GAF) and other consensus ratings of study psychiatrists.
  
  
  RESULTS
  We used nonlinear modeling (locally weighted scatterplot smoothing and spline regression) to examine links between 4-year symptom variables (ratio of nonaffective psychosis to mood disturbance, duration of mania/hypomania, depression, and psychosis) and 10-year outcomes. Nonaffective psychosis ratio exhibited a sharp discontinuity-10 days or more of psychosis outside mood episodes predicted an 11-point decrement in GAF-consistent with the kraepelinian dichotomy. Duration of mania/hypomania showed 2 discontinuities demarcating 3 groups: mania absent, episodic mania, and chronic mania (manic/hypomanic >1 year). The episodic group had a better outcome compared with the mania absent and chronic mania groups (12-point and 8-point difference on GAF). Duration of depression and psychosis had linear associations with worse outcome.
  
  
  CONCLUSIONS
  Our data support the kraepelinian dichotomy, although the study requires replication. A boundary between schizoaffective disorder and schizophrenia was not observed, which casts further doubt on schizoaffective diagnosis. Co-occurring schizophrenia and mood disorder may be better coded as separate diagnoses, an approach that could simplify diagnosis, improve its reliability, and align it with the natural taxonomy.
authors.affiliation: Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, New York.
authors.forename: Roman
authors.initials: R
authors.lastname: Kotov
authors.forename: Shirley H
authors.initials: SH
authors.lastname: Leong
authors.forename: Ramin
authors.initials: R
authors.lastname: Mojtabai
authors.forename: Ann C Eckardt
authors.initials: AC
authors.lastname: Erlanger
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Fochtmann
authors.forename: Eduardo
authors.initials: E
authors.lastname: Constantino
authors.forename: Gabrielle A
authors.initials: GA
authors.lastname: Carlson
authors.forename: Evelyn J
authors.initials: EJ
authors.lastname: Bromet
mesh_terms: D000293:Adolescent; D000328:Adult; D001714:Bipolar Disorder / Q000145:classification* / Q000175:diagnosis / Q000453:epidemiology; D018450:Disease Progression; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011618:Psychotic Disorders / Q000145:classification* / Q000175:diagnosis / Q000453:epidemiology; D012044:Regression Analysis; D013997:Time Factors; D055815:Young Adult